<!DOCTYPE html>
<html xmlns:th="http://www.thymeleaf.org"
      th:replace="fragments/layout(title='信息登记-新增',cssPaths='/static/css/baseinfo/yljg.css',jsPaths='/static/js/elder/elderly/addone.js')">
<div class="right" th:fragment="right">
    <!--面包屑-->
    <div class="breadcrumb layui-bg-gray">
                <span class="layui-breadcrumb" lay-separator=">">
                    <a th:href="@{/}">首页</a>
                      <a href="/gbElderly/elist">老人管理</a>
                        <a href="/enterElderly">信息登记</a>
                        <a><cite>新增</cite></a>
                </span>
    </div>

    <!--主体内容区-->
    <div class="form-content">
            <div class="layui-tab" lay-filter="demo">
                <ul class="layui-tab-title">
                    <li class="layui-nav-item layui-this" lay-id="one">1.基本信息登记</li>
                    <li class="layui-nav-item layui-disabled" lay-id="two">2.家属信息登记</li>
                    <li class="layui-nav-item layui-disabled"  lay-id="three">3.健康信息登记</li>
                    <li class="layui-nav-item layui-disabled" lay-id="four">4.资料附件上传</li>
                </ul>
                <div class="layui-tab-content">
                    <div class="layui-tab-item layui-show">
                        <form class="layui-form" th:action="@{/enterElderly/elderSave}" method="post">
                            <div class="layui-row">
                                <div class="layui-col-md4 layui-row" style="border-bottom: 0;">
                                    <div class="layui-col-md12">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label must">姓名</label>
                                            <div class="layui-input-block">
                                                <input type="text" name="name" maxlength="10" lay-verify="required"
                                                       placeholder="请输入老人姓名" autocomplete="off" class="layui-input" id="name">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md12">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label must">身份证号</label>
                                            <div class="layui-input-block">
                                                <input type="text" name="idNo" id="idNo" data-label="身份证号"
                                                       lay-verify="required|identity|only" placeholder="请输入老人身份证号"
                                                       autocomplete="off" class="layui-input" >
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md6">
                                        <div class="layui-form-item" >
                                            <label class="layui-form-label must">性别</label>
                                            <div class="layui-input-block" style="width: 150px;">
                                                <select name="sex" lay-verify="required">
                                                    <option value="">请选择</option>
                                                    <option value="男">男</option>
                                                    <option value="女">女</option>
                                                </select>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md6">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label must">生日</label>
                                            <div class="layui-input-block" >
                                                <input type="text" name="birthday" id="birthday" readonly lay-verify="required"
                                                       placeholder="请选择生日" autocomplete="off" class="layui-input" style="width: 150px;">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md6">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label must">人员类别</label>
                                            <div class="layui-input-block"  style="width: 150px;">
                                                <select name="personCategory" lay-verify="required">
                                                    <option value="">请选择</option>
                                                    <option value="0">老年人</option>
                                                    <option value="1">残疾人</option>
                                                    <option value="2">未成年人</option>
                                                </select>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md6">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label must">户籍类别</label>
                                            <div class="layui-input-block"  style="width: 150px;">
                                                <select name="censusRegisterCategory" lay-verify="required">
                                                    <option value="">请选择</option>
                                                    <option value="0">农业</option>
                                                    <option value="1">城市</option>
                                                </select>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="layui-col-md12">
                                        <div class="layui-form-item">
                                            <label class="layui-form-label">联系电话</label>
                                            <div class="layui-input-block">
                                                <input type="text" name="phone"  placeholder="请输入手机号码"
                                                       autocomplete="off" class="layui-input">
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="layui-col-md4">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label" style="line-height: 174px;">头像</label>
                                        <div class="layui-input-block">
                                            <div style="position: relative;width: 150px;height: 174px;background: floralwhite;text-align: center;line-height: 174px;">
                                                <img src="/static/imgs/txsc.png" alt="头像" id="avatarimg" style="cursor: pointer;">
                                            </div>
                                            <input type="hidden" id="avatar" name="avatar">
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md4">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label">婚姻状况</label>
                                        <div class="layui-input-block">
                                            <select name="wedding">
                                                <option value="1">未婚</option>
                                                <option value="2" selected>已婚</option>
                                                <option value="3">丧偶</option>
                                                <option value="4">离婚</option>
                                                <option value="5">未说明的婚姻状况</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                                <div class="layui-col-md4">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label">政治面貌</label>
                                        <div class="layui-input-block">
                                            <input type="text" name="zmstatus" maxlength="10"
                                                   placeholder="请输入政治面貌" autocomplete="off" class="layui-input">
                                            </select>
                                        </div>
                                    </div>
                                </div>

                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md4">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label ">文化程度</label>
                                        <div class="layui-input-block">
                                            <select name="education" >
                                                <option value=""></option>
                                                <option value="1">文盲</option>
                                                <option value="2">小学</option>
                                                <option value="3">初中</option>
                                                <option value="4">高中/技校/中专</option>
                                                <option value="5">大学专科及以上</option>
                                                <option value="6">不详</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label ">经济来源</label>
                                        <div class="layui-input-block">
                                            <select name="fmoney">
                                                <option value=""></option>
                                                <option value="1">退休金/养老金</option>
                                                <option value="2">子女补贴</option>
                                                <option value="3">亲友资助</option>
                                                <option value="4">其它补贴</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label">民族</label>
                                        <div class="layui-input-block">
                                            <input type="text" name="nation" maxlength="10" placeholder="请输入民族" autocomplete="off"
                                                   class="layui-input">
                                        </div>
                                    </div>
                                </div>
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label ">原居住情况</label>
                                        <div class="layui-input-block">
                                            <select name="support">
                                                <option value="1">独居</option>
                                                <option value="2">与配偶/伴侣居住</option>
                                                <option value="3">与子女居住</option>
                                                <option value="4">与父母居住</option>
                                                <option value="5">与兄弟姐妹居住</option>
                                                <option value="6">与其他亲属居住</option>
                                                <option value="7">与非亲属关系的人居住</option>
                                                <option value="8">养老机构</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label ">宗教信仰</label>
                                        <div class="layui-input-block">
                                            <select name="faith">
                                                <option value="0">无</option>
                                                <option value="1">有</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label">医保卡号</label>
                                        <div class="layui-input-block">
                                            <input type="text" name="ybnum" maxlength="10" placeholder="医保卡号" autocomplete="off"
                                                   class="layui-input">
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label">特困供养证号</label>
                                        <div class="layui-input-block">
                                            <input type="text" name="fiveNo" maxlength="10" placeholder="请输入特困供养证号" autocomplete="off"
                                                   class="layui-input">
                                        </div>
                                    </div>
                                </div>
                                <div class="layui-col-md4 ">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label ">医疗费用支付方式</label>
                                        <div class="layui-input-block">
                                            <select name="zfstatus">
                                                <option value="1">城镇职工基本医疗保险</option>
                                                <option value="2">城镇居住基本医疗保险</option>
                                                <option value="3">新型农村合作医疗</option>
                                                <option value="4" selected>贫困救助</option>
                                                <option value="5">商业医疗保险</option>
                                                <option value="6">全公费</option>
                                                <option value="7">全自费</option>
                                                <option value="8">其它</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="layui-row">
                                <div class="layui-col-md12">
                                    <div class="layui-form-item">
                                        <label class="layui-form-label must">户籍地址</label>
                                        <div class="layui-input-inline">
                                            <!--<div class="city-picker-selector" id="city-picker-selector1"></div>-->
                                            <select id="province" lay-filter="province" lay-verify="required">
                                                <option value="">请选择省</option>
                                                <option th:each="p : ${provinceList}" th:value="${p.id}" th:text="${p.name}"></option>
                                            </select>
                                        </div>
                                        <div class="layui-input-inline">
                                            <select id="city" lay-filter="city" lay-verify="required">
                                                <option value="">请选择市</option>

                                            </select>
                                        </div>
                                        <div class="layui-input-inline">
                                            <select id="area" lay-filter="area" lay-verify="required">
                                                <option value="">请选择区(县)</option>

                                            </select>
                                        </div>
                                        <div class="layui-input-inline">
                                            <select id="town" lay-filter="town" lay-verify="required">
                                                <option value="">请选择乡镇(街道)</option>

                                            </select>
                                        </div>
                                        <div class="layui-input-inline">
                                            <select id="village" lay-filter="village" lay-verify="required">
                                                <option value="">请选择社区(村)</option>
                                            </select>
                                        </div>
                                        <input type="hidden" id="provinceCode" name="provinceCode">
                                        <input type="hidden" id="cityCode" name="cityCode">
                                        <input type="hidden" id="areaCode" name="areaCode">
                                        <input type="hidden" id="townCode" name="townCode">
                                        <input type="hidden" id="villageCode" name="villageCode">
                                        <input type="hidden" id="provinceName" name="provinceName">
                                        <input type="hidden" id="cityName" name="cityName">
                                        <input type="hidden" id="areaName" name="areaName">
                                        <input type="hidden" id="townName" name="townName">
                                        <input type="hidden" id="villageName" name="villageName">
                                    </div>
                                    <div class="layui-col-md7 layui-col-md-offset1 layui-input-block">
                                        <input type="text" name="address" maxlength="100" lay-verify="required" placeholder="请输入详细地址"
                                               autocomplete="off" class="layui-input">
                                    </div>
                                </div>
                            </div>
                            <div class="layui-form-item">
                                <div class="layui-input-block">
                                    <button class="layui-btn  layui-btn-normal" lay-submit lay-filter="submitBtn">保存</button>
                                    <a href="/enterElderly" class="layui-btn layui-btn-primary">返回</a>
                                </div>
                            </div>
                        </form>
                    </div>
                </div>
            </div>
    </div>
</div>
</html>